Will Calcaneal Apophysitis Often Demand Surgical Treatment?
Overview
Sever?s Disease is often misdiagnosed as a simple growing pains and affects boys far more often than girls, especially between the ages of 8 and 14. It is extremely common in children that play Soccer, Basketball, And Hockey. However it is not limited to these sports alone, nor is it simply a pre-season type condition related to fitness. Sever?s Disease sounds terrible, but there is no need to panic as it is not a contagious or incurable condition. In children, there is a growth plate in the heel bone, which at puberty becomes solid and forms part of the heel, however prior to puberty it can cause pain if the child?s foot rolls inwards or outwards too much, causing increased stress on this growth plate and inturn causes pain.
Causes
The heel bone sometimes grows faster than the leg muscles (including the calf muscles) and tendons (including the Achilles tendon) during the early puberty growth spurt. The different growth rate in these structures can cause lower leg muscles and tendons to become overstretched and tight, which makes the heel less flexible and puts excessive pressure on the heel growth plate. The Achilles tendon, the strongest tendon in the body, attaches to the heel growth plate, and repetitive stress on this structure, especially if it?s already tight, can damage the growth plate, leading to tenderness, swelling, and pain. Activities that involve running or jumping, such as soccer, gymnastics, track, and basketball, can place significant stress on a tight Achilles tendon and contribute to the onset of Sever?s disease. Ill-fitting shoes can also contribute to this health problem by failing to provide the right kind of support or by rubbing against the back of heel. The following factors may increase the likelihood of Sever?s disease in kids or young teens. Wearing footwear that is too narrow in the toe box. Leg length inequality. Obesity or carrying excess bodyweight. Excessive foot and ankle pronation.
Symptoms
On examination, the typical signs are tenderness on palpation of the heel, particularly on deep palpation at the Achilles tendon insertion. Pain on dorsiflexion of the ankle, particularly when doing active toe raises; forced dorsiflexion of the ankle is also uncomfortable. Swelling of the heel, usually mild. Calcaneal enlargement, in long-standing cases.
Diagnosis
Sever?s disease can be diagnosed based on the symptoms your child has. Your child?s doctor will conduct a physical examination by squeezing different parts of your child?s foot to see if they cause any pain. An X-ray may be used to rule out other problems, such as a broken bone or fracture.
Non Surgical Treatment
Management consists of explanation of what's happening and advice on activity modification to get it to settle. Icing after activity and heating during breaks in activity also often help. Local treatment with electrotherapy may be indicated in the acute stage or to help settle pain for a specific activity/competition. Stretches will be advised and the child may require orthotics to control foot position. A heel raise or heel cups may also help. Strapping may be of some benefit. The mainstay of treatment however is the icing and activity modification and reassurance that the condition is self-limiting, this may take up to 2 years.
Recovery
Sever?s disease is self-recovering, meaning that it will go away on its own when sport is reduced or as the bones mature. The condition is not expected to create any long-term disability, and expected to subside in 2-8 weeks. However, while the disease does subside quickly, it can recur, for example at the start of a new sports season or during a growth spurt. If your pain does return you will need to re-introduce the above treatment plan. If the pain persists please seek further advice from your GP.
Sever?s Disease is often misdiagnosed as a simple growing pains and affects boys far more often than girls, especially between the ages of 8 and 14. It is extremely common in children that play Soccer, Basketball, And Hockey. However it is not limited to these sports alone, nor is it simply a pre-season type condition related to fitness. Sever?s Disease sounds terrible, but there is no need to panic as it is not a contagious or incurable condition. In children, there is a growth plate in the heel bone, which at puberty becomes solid and forms part of the heel, however prior to puberty it can cause pain if the child?s foot rolls inwards or outwards too much, causing increased stress on this growth plate and inturn causes pain.
Causes
The heel bone sometimes grows faster than the leg muscles (including the calf muscles) and tendons (including the Achilles tendon) during the early puberty growth spurt. The different growth rate in these structures can cause lower leg muscles and tendons to become overstretched and tight, which makes the heel less flexible and puts excessive pressure on the heel growth plate. The Achilles tendon, the strongest tendon in the body, attaches to the heel growth plate, and repetitive stress on this structure, especially if it?s already tight, can damage the growth plate, leading to tenderness, swelling, and pain. Activities that involve running or jumping, such as soccer, gymnastics, track, and basketball, can place significant stress on a tight Achilles tendon and contribute to the onset of Sever?s disease. Ill-fitting shoes can also contribute to this health problem by failing to provide the right kind of support or by rubbing against the back of heel. The following factors may increase the likelihood of Sever?s disease in kids or young teens. Wearing footwear that is too narrow in the toe box. Leg length inequality. Obesity or carrying excess bodyweight. Excessive foot and ankle pronation.
Symptoms
On examination, the typical signs are tenderness on palpation of the heel, particularly on deep palpation at the Achilles tendon insertion. Pain on dorsiflexion of the ankle, particularly when doing active toe raises; forced dorsiflexion of the ankle is also uncomfortable. Swelling of the heel, usually mild. Calcaneal enlargement, in long-standing cases.
Diagnosis
Sever?s disease can be diagnosed based on the symptoms your child has. Your child?s doctor will conduct a physical examination by squeezing different parts of your child?s foot to see if they cause any pain. An X-ray may be used to rule out other problems, such as a broken bone or fracture.
Non Surgical Treatment
Management consists of explanation of what's happening and advice on activity modification to get it to settle. Icing after activity and heating during breaks in activity also often help. Local treatment with electrotherapy may be indicated in the acute stage or to help settle pain for a specific activity/competition. Stretches will be advised and the child may require orthotics to control foot position. A heel raise or heel cups may also help. Strapping may be of some benefit. The mainstay of treatment however is the icing and activity modification and reassurance that the condition is self-limiting, this may take up to 2 years.
Recovery
Sever?s disease is self-recovering, meaning that it will go away on its own when sport is reduced or as the bones mature. The condition is not expected to create any long-term disability, and expected to subside in 2-8 weeks. However, while the disease does subside quickly, it can recur, for example at the start of a new sports season or during a growth spurt. If your pain does return you will need to re-introduce the above treatment plan. If the pain persists please seek further advice from your GP.
What Are The Causes And Indicators Of An Achilles Tendon Rupture
Overview
Achilles tendon rupture is when the achilles tendon breaks. The achilles is the most commonly injured tendon. Rupture can occur while performing actions requiring explosive acceleration, such as pushing off or jumping. The male to female ratio for Achilles tendon rupture varies between 7:1 and 4:1 across various studies.
Causes
An Achilles tendon injury might be caused by several factors. Overuse. Stepping up your level of physical activity too quickly. Wearing high heels, which increases the stress on the tendon. Problems with the feet, an Achilles tendon injury can result from flat feet, also known as fallen arches or overpronation. In this condition, the impact of a step causes the arch of your foot to collapse, stretching the muscles and tendons. Muscles or tendons in the leg that are too tight. Achilles tendon injuries are common in people who participate in the following sports. Running. Gymnastics. Dance. Football. Baseball. Softball. Basketball. Tennis. Volleyball. You are more likely to tear an Achilles tendon when you start moving suddenly. For instance, a sprinter might get one at the start of a race. The abrupt tensing of the muscle can be too much for the tendon to handle. Men older than age 30 are particularly prone to Achilles tendon injuries.
Symptoms
An Achilles tendon rupture is when the tendon that connects the heel bone to the calf muscle tears and the fibers separate. This happens mostly between the ages of 30 and 50, and usually is caused by sports. Symptoms of Achilles tendon rupture include the following. A pop or snap when the tendon tears. Severe pain in back of the ankle, making it nearly impossible to walk. Swelling and discoloration. Tenderness. Inability to rise on toes. A gap in the back of the ankle where the tendons are separated.
Diagnosis
To diagnose an Achilles tendon injury, your health care provider will give you a thorough physical exam. He or she may want to see you walk or run to look for problems that might have contributed to your Achilles tendon injury.
Non Surgical Treatment
Non-operative treatment consists of placing the foot in a downward position [equinus] and providing relative immobilization of the foot in this position until the Achilles has healed. This typically involves some type of stable bracing or relative immobilization for 6 weeks, often with limited or no weight bearing. The patient can then be transitioned to a boot with a heel lift and then gradually increase their activity level within the boot. It is very important that the status of the Achilles is monitored throughout non-operative treatment. This can be done by examination or via ultrasound. If there is evidence of gapping or non-healing, surgery may need to be considered. Formal protocols have been developed to help optimize non-operative treatments and excellent results have been reported with these protocols. The focus of these treatments is to ensure that the Achilles rupture is in continuity and is healing in a satisfactory manner. The primary advantage of non-operative treatment is that without an incision in this area, there are no problems with wound healing or infection. Wound infection following Achilles tendon surgery can be a devastating complication and therefore, for many patients, non-operative treatment should be contemplated. The main disadvantage of non-operative treatment is that the recovery is probably slower. On average, the main checkpoints of recovery occur 3-4 weeks quicker with operative treatment than with non-operative treatment. In addition, the re-rupture rate appears to be higher with some non-operative treatments. Re-rupture typically occurs 8-18 months after the original injury. 
Surgical Treatment
Surgical repair is a common method of treatment of acute Achilles rupture in North America because, despite a higher risk of overall complications, it has been believed to offer a reduced risk of rerupture. However, more recent trials, particularly those using functional bracing with early range of motion, have challenged this belief. The aim of this meta-analysis was to compare surgical treatment and conservative treatment with regard to the rerupture rate, the overall rate of other complications, return to work, calf circumference, and functional outcomes, as well as to examine the effects of early range of motion on the rerupture rate.
Cause Of Acquired Flat Foot
Overview
Many foot problems can be contributed to Adult Acquired Flatfoot Deformity (AAFD), a foot and ankle condition that causes fallen arch of the foot. AAFD is also referred to as Posterior Tibial Tendon Dysfunction (PTTD). The posterior tibial tendon serves as the principal supporting structure of your foot. When this ligament is injured overtime the arches start to flatten, leaving you with a painful foot condition. AAFD is more common in women ages 39 - 65 than men. 
Causes
There are numerous causes of acquired Adult Flatfoot, including, trauma, fracture, dislocation, tendon rupture/partial rupture or inflammation of the tendons, tarsal coalition, arthritis, neuroarthropathy and neurologic weakness. The most common cause of acquired Adult Flatfoot is due to overuse of a tendon on the inside of the ankle called the posterior tibial tendon. This is classed as - posterior tibial tendon dysfunction. What are the causes of Adult Acquired flat foot? Trauma, Fracture or dislocation. Tendon rupture, partial tear or inflammation. Tarsal Coalition. Arthritis. Neuroarthropathy. Neurological weakness.
Symptoms
The first stage represents inflammation and symptoms originating from an irritated posterior tibial tendon, which is still functional. Stage two is characterized by a change in the alignment of the foot noted on observation while standing (see above photos). The deformity is supple meaning the foot is freely movable and a ?normal? position can be restored by the examiner. Stage two is also associated with the inability to perform a single-leg heel rise. The third stage is dysfunction of the posterior tibial tendon is a flatfoot deformity that becomes stiff because of arthritis. Prolonged deformity causes irritation to the involved joints resulting in arthritis. The fourth phase is a flatfoot deformity either supple (stage two) or stiff (stage 3) with involvement of the ankle joint. This occurs when the deltoid ligament, the major supporting structure on the inside of the ankle, fails to provide support. The ankle becomes unstable and will demonstrate a tilted appearance on X-ray. Failure of the deltoid ligament results from an inward displacement of the weight bearing forces. When prolonged, this change can lead to ankle arthritis. The vast majority of patients with acquired adult flatfoot deformity are stage 2 by the time they seek treatment from a physician.
Diagnosis
The diagnosis of posterior tibial tendon dysfunction and AAFD is usually made from a combination of symptoms, physical exam and x-ray imaging. The location of pain, shape of the foot, flexibility of the hindfoot joints and gait all may help your physician make the diagnosis and also assess how advanced the problem is.
Non surgical Treatment
Because of the progressive nature of PTTD, early treatment is critical. If treated soon enough, symptoms may resolve without the need for surgery and progression of the condition can be stopped. If left untreated, PTTD may create an extremely flat foot, painful arthritis in the foot and ankle, and will limit your ability to walk, run, and other activities. Your podiatrist may recommend one or more of these non-surgical treatments to manage your PTTD. Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may recommend an ankle brace or a custom orthotic device that fits into your shoe to support the arch. Immobilization. A short-leg cast or boot may be worn to immobilize the foot and allow the tendon to heal. Physical therapy. Ultrasound therapy and stretching exercises may help rehabilitate the tendon and muscle following immobilization. Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. Shoe modifications. Your foot and ankle surgeon may recommend changes in your footwear. 
Surgical Treatment
Surgery is usually performed when non-surgical measures have failed. The goal of surgery is to eliminate pain, stop progression of the deformity and improve a patient?s mobility. More than one technique may be used, and surgery tends to include one or more of the following. The tendon is reconstructed or replaced using another tendon in the foot or ankle The name of the technique depends on the tendon used. Flexor digitorum longus (FDL) transfer. Flexor hallucis longus (FHL) transfer. Tibialis anterior transfer (Cobb procedure). Calcaneal osteotomy - the heel bone may be shifted to bring your heel back under your leg and the position fixed with a screw. Lengthening of the Achilles tendon if it is particularly tight. Repair one of the ligaments under your foot. If you smoke, your surgeon may refuse to operate unless you can refrain from smoking before and during the healing phase of your procedure. Research has proven that smoking delays bone healing significantly.
